Medical Release

We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or specific supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or medical center, whether such diagnosis or treatment is rendered at the office of said physician and said hospital or medical center.

                The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.  Should it be necessary for our/my child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.

Participant Signature________________________________________________Date_________

Parent/Gaurdian Signature___________________________________________ Date_________

Phone Number____________________Birth Date__________________________Age________

Name of Parent(s) or Legal Gaurdians(s)_____________________________________________

Secondary Phone Number (in case of emergency)______________________________________

Insurance Company and Number ___________________________________________________

Please attach a photocopy of your current insurance card  (front and back)

Liability Agreement:

            In consideration for permission and support by Evangelical Youth Fellowship and all participating churches for me to participate in and receive accommodation for Velocity 2007, June 25-30, 2007, I, the undersigned, for myself, my heirs, executors, administrators and assigns do hereby release, hold harmless, indemnify, waive and discharge Evangelical Youth Fellowship and all participating churches, staff members, and their agents (whether paid or volunteer) from and against any and all claims, demands, actions, or causes of action arising from any injuries or damages I may suffer or sustain by my participation in Velocity 2007.  Furthermore, in full recognition and appreciation of the potential dangers and hazards inherent in travel to and participation in Velocity 2007, I do hereby agree to assume all the risks and responsibilities surrounding my participation in this activity or any other activities undertaken in addition thereto.  I authorize my child to participate in the following special activities:  _________Canoeing ________ Paintball ______ Camping _______ Golf _______ Hiking _______Swimming

Photo Release

            I certify that photographs or videotape pictures of my child participating in Evangelical Youth Fellowship programs may be reproduced and utilized in promotional materials for the conference.

The undersigned acknowledges having read and understood the foregoing informed consent form.  In witness whereof, I have caused this release to be executed this ________ day of ______________, 2007.

Participant’s Signature___________________________________________________________

Participant’s Printed Name________________________________________________________

Parent/Guardian Signature________________________________________________________

Address ______________________________________________________________________

Phone:  Work (    )___________________  Home (    )_________________________